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PERMITTEE NAME/ADDRESS Undudr FatiGfs ~"amt/Llru(inn i/DiQnsnf) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />~N PiA1~kiL Ef? <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />F <br /><. {'i~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />~ 1 <br />r <br />• <br /> MEASUREMENT i - <br /> PERMIT ~ • <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I resin under pa•null) 11( IYw Ihal IhH J~xumem and all euuchmenb were ~' ~~ <br />I TELEPHONE DATE <br /> prrpan•J wider nn dirrrtian or .wpen ivnn m urcorduncr with a a~ arm deai>;txd <br /> to u+.un• that gtmli0ed peralnnrl proptrlc gather and rvuhwlr the information ` ' <br />• <br /> auhmiuad. NarJ on nn inquire n! the prrwn or q~nnn. who manage the a~.lrnt. J <br />7 ~ . _~ <br /> ur thine pesos. direrUa ra•a{umahle for g:n ha•ring the in(ontmtiun. the m(ormation <br /> wbmittrd is, to the Iw~+t of ma knowledge and Ix•lir(.Inle, uacurate, alul cnmplatr. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am aware that there an• signifiaam pa•naUics fur ,ubmitting fal.e information. <br />including the pw.ibJit~ ..f fine unJ impriwnmem for knowing aioLttinn,, <br />OF[fICER OR AUTHORIZED AGENT AREA <br />DE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-t IRev. 3/99) Previous editions may tre used This is a •~-dart' firm. <br />